By Dr Minh Alexander NHS whistleblower and former consultant psychiatrist, 29 October 2016
The politicised Care Quality Commission (CQC) continues to astound us with its arbitrary ways. Jeremy Hunt cashed in on a public relations opportunity after the CQC rated Northumberland Tyne and Wear Trust “Outstanding”. However, serious questions arise about the validity of CQC’s rating in terms of patient experience data, the number of complaints upheld by PHSO, the highest rate of violent incidents nationally and a significant increase in use of dangerous face down restraint. A backdrop of whistleblower reprisal and other staff mistreatment adds to the doubts. CQC’s claims lack credibility in the face of obvious, severe de-funding and downgrading of mental health services. However, they do serve Mr Hunt well.
CQC’s recent ‘Outstanding’ rating on Northumberland Tyne and Wear was a first for a mental health trust.  The inspection had been chaired by no less that Paul Lelliott , CQC Deputy Chief Inspector of Hospitals, and the rating came at a handy time for Jeremy Hunt.
The government’s studied neglect of mental health services had brought years of awkward headlines, intensified recently by the scandal of hundreds of un-investigated deaths at Southern Health trust.  Opposition politicians have exposed continuing cuts to mental health , despite government spin to the contrary. Suicides have continued rising and deaths continue to be criticised by coroners. Bed shortages remain visibly acute.
So sure enough, after CQC hung out the good news bunting at Northumberland, the Minister popped up for a photo opp:
But did long troubled Northumberland really merit a rating of ‘Outstanding’? Where the slippery CQC is concerned, it’s always wise to check the small print.
Whistleblowers are conscious of the treatment of psychiatrist Dr Antoinette Geoghegan, who suffered a terrible ordeal at the hands of the trust after she whistleblew on unsafe practices.  After she won at the Employment Tribunal, Northumberland appealed and subjected her to yet more years of gruelling litigation. She eventually won at the Court of Appeal last year, at great personal cost.
There have also been other staff who have been mistreated by the Trust and who had Employment Tribunal findings in their favour, over matters such as disability discrimination and detriment for trade union activity. 
A glance at the most recent staff survey (2015)  shows above average scores on staff engagement, and favourable scores on bullying indices, but not the best.
A check of Northumberland’s performance on the latest patient survey (2015) – with a questionnaire response rate of only 27% – does not look at all ‘Outstanding”. See Table 1.
Table 1. CQC patient survey 1 October 2015, based on responses by 227 people (after questionnaires had been sent to 850 people):
A grading of “About the same” as other trusts is not saying much when CQC has now admitted that almost two thirds of mental health trusts, after years of cuts, ‘Require Improvement’.
A peek at patient feedback on NHS choices  shows 22 entries that are mostly negative with either one or no star ratings, dating back to 2012. The average rating is 1.3 stars. In the year before CQC last inspected, there were seven critical comments: “rude and abrupt…poor service…poor administration and lack of communication…no access to ANY NHS services…disappointing in a time of need…why bother….unfit for purpose, lacking care and compassion…”.
A peek at Patient Opinion  doesn’t look clearly ‘Outstanding’ either:
Some of the comments, from both patients and families, are very distressed. For example, two months ago:
“I’ve been left to feel like my life is worth nothing and left me feeling just to give up and not try anymore. They’ve taken every ounce of fight out of me I give up trying they make it too hard, grind you down. I now feel am worth nothing they’ve ground me down to the point that I give up don’t know who to ask for help anymore life seems pointless cause the staff at the cmht just don’t care whether patient are alive or dead.”
And 15 months ago:
“My sister is a patient in St Georges and i can’t believe what i see every day i visit. Today was the last straw. My sister has not had her clothes changed in a week or washed, i was told if she did’nt want to do these things that was ok by them….parients like my sister are left to fend for themselves whatever their mental capacity. An extremely worried sister.”
There are also some very good comments, but the number of criticisms does not support an impression of a consistently sound and adequately resourced service.
A flick through the PHSO’s data reveals that Northumberland was the mental health trust with the most complaints upheld against it in 2014/15 – see Table 2. Well, that’s sort of ‘Outstanding’….
Northumberland has also tended to top the violence charts. NHS Protect data shows that Northumberland has led the field nationally on reported assaults, by some, for three years. 
Table 3. Reported assaults at Northumberland Tyne and Wear NHS Foundation Trust
Table 4. NHS trusts with the highest numbers of reported assaults in 2014/15
In terms of the rate of violence, as defined by assaults per 1000 staff, Northumberland was the clear leader at a whopping 600 assaults per 1000 staff in 2014/15.
Not least of all, an investigation by the charity MIND in 2013 resulted in a scandal because Northumberland and Southern Health together accounted for about half of all face down restraint incidents in mental health trusts in 2011/12 – with 923 and 810 incidents respectively.  Face down restraint is much more dangerous for patients. The variations between trusts could not be accounted for by differences in trust size and population alone.
The MIND data on Northumberland’s restraint incidents in 2011/12 can be found here:
In response, the government tightened up guidance. Face down restraint was thereafter supposed to be kept to an absolute minimum, and used for the shortest time possible. 
There has been little progress though, as confirmed by recent FOI data. 
At Northumberland, the rate of face down restraints appears to have increased since the MIND report in 2013. As CQC’s latest report admits, between just 1 November 2015 and 30 April 2016
“There were 1,481 incidents of prone [face down] restraint which accounted for 37% of the restraint incidents…” 
Pro rata, this equates to 2962 incidents of face down restraint a year – over three times the Northumberland rate in 2011/12. It is very clearly not the minimal use required by NICE.
Excessive use of restraint can be a sign that mental health services are over stretched, and that staff are under strain and not adequately supported.
So how on earth did CQC translate all this into an ‘Outstanding’ rating?
Logic and evidence don’t seem to have much to do with it. What then, are the explanations that are left?
I think Mr Hunt could probably answer that one.
God help our poor NHS, patients and staff.
CQC deaths review: All fur coat 25 September 2016
In CQC’s hands, reporting of unmet need and harm, including deaths, is akin to a game of Find The Lady. This summarises the pattern of patchy reporting that hides as much as it reveals.
Letter to parliament: CQC’s inconsistent regulation of restraint in mental health 31 October 2016
An analysis of CQC’s reporting of restraint practices in its inspection reports on mental health trusts set against FOI data from mental health trusts about their use of restraint. This showed incomplete reporting and questionable inconsistency in CQC’s approach.
 First mental health trusts rated outstanding. Joe Gammie, Health Service Journal 1 September 2016
 CQC inspection report on Northumberland Tyne and Wear 1 September 2016
 Mazars report of an independent review of people with a learning disability or mental health problem in contact with Southern Health NHS Foundation Trust April 2011 to March 2015
 Jeremy Hunt breaks his pledge to raise spending on mental health, Jason Beattie Mirror 22 September 2016
 Private Eye March 2015, on Antoinette Geoghegan’s ordeal & eventual vindication by the Court of Appeal.
 MP will raise nurse Yunus Bakhsh’s plight in parliament, The Journal 25 June 2013
 Northumberland Tyne and Wear NHS Foundation Trust, NHS Staff Survey 2015
 NHS Choices – patient feedback on Northumberland Tyne and Wear NHSFT
 Patient Opinion – patient feedback on Northumberland Tyne and Wear NHSFT
 NHS Protect data on reported assaults
 Mental Health Crisis Care, physical restraint in crisis, MIND June 2013
‘Excessive’ use of face down restraint in mental health hospitals, Mark Easton BBC, 18 June 2013
 Violence and aggression. Short term management in mental health, health and community settings. NICE guideline NG10 May 2015
 Surge in number of mental health patients being physically restrained criticised by former Health Minister, Rob Merrick, Independent 21 September 2016